Penny Hollander Feldman

When the Caregiver Needs Care: The Plight of Vulnerable Caregivers

OBJECTIVESnThis study examined the characteristics, activities, and challenges of high-risk informal caregivers.nnnMETHODSnTelephone interviews were conducted with a nationally representative cross-section of 1002 informal caregivers. Vulnerable caregivers with poor health or a serious health condition were compared with nonvulnerable caregivers.nnnRESULTSnThirty-six percent of caregivers were vulnerable. Compared with nonvulnerable caregivers, vulnerable caregivers were more likely to have difficulty providing care, to provide higher-intensity care, to report that their physical health had suffered since becoming a caregiver, to be aged 65 years or older, to be married, and to have less than 12 years of education.nnnCONCLUSIONSnReliance on informal caregivers without considering the caregivers ability to provide care can create a stressful and potentially unsafe environment for the caregiver and the care recipient.

Risk factors for repeated hospitalizations among home healthcare recipients.

One indicator of quality home healthcare is the prevention of rehospitalization. This study explored factors that place patients at risk for repeat hospitalizations after home healthcare admission. One year of outcomes assessment information data from a large home health agency was used to identify 7,393 patients who had at least one episode of rehospitalization. Results revealed that after the data had been adjusted for age and gender, a number of demographic, clinical, and functional factors predicted repeat hospitalizations. Home health agencies that focus on these risk factors may improve the effectiveness and efficiency of their efforts to prevent rehospitalization.

Activation among chronically ill older adults with complex medical needs: challenges to supporting effective self-management.

Successful chronic care ideally involves patient engagement, but little is known about chronically ill older adults ability to self-manage their health. This study examines activation among hypertensive patients older than 65 years. Almost 60% of participants scored in the bottom half of the activation scale; only 8% scored at the highest level. Higher activation was associated with higher self-ratings of health, health literacy, and receipt of patient-centered care, shorter lengths of stay, and lower depression and hearing impairment levels. Effective self-management support for chronically ill elders will likely require varied strategies and may need to address depression, health literacy, and/or hearing impairments.

Medication Management: evidence Brief

The Medication Management Evidence Brief included in this issue is part of a National Framework for Geriatric Home Care Excellence to benefit older patients through practice improvement efforts. The Center for Home Care Policy & Research, Visiting Nurse Service of New York, spearheaded this initiative with funding from the John A. Hartford Foundation. A National Advisory Council of experts in geriatrics and home care guided development of the Framework by building on the foundation of what older adults want from home care (eg, quality of life, choices, and optimal function). They identified cross-cutting principles of high quality care (eg, relationship-centered, interdisciplinary, evidence-based, individualized, focused on communication, and care over the long-term) and strategies for implementing best practices, which are summarized in an Initiative Overview Brief. In addition to Medication Management, Evidence Briefs were produced on five other key practice areas for geriatric home care. The Framework recommendations and all the briefs are available at http://champ-program.org/framework/.

Patient Activation and Disparate Health Care Outcomes in a Racially Diverse Sample of Chronically Ill Older Adults

The Patient Activation Measure (PAM) assesses people’s ability to self-manage their health. Variations in PAM score have been linked with health behaviors, outcomes, and potential disparities. This study assessed the relative impacts of activation, socio-demographic and clinical factors on health care outcomes in a racially diverse sample of chronically ill, elderly homecare patients. Using survey and administrative data from 249 predominantly non-White patients, logistic regression was conducted to examine the effects of activation level and patient characteristics on the likelihood of subsequent hospitalization and emergency department (ED) use. Activation was not a significant predictor of hospitalization or ED use in adjusted models. Non-Whites were more likely than Whites to have a hospitalization or ED visit. Obesity was a strong predictor of both outcomes. Further research should examine potential sources of disadvantage among chronically ill homecare patients to design effective interventions to reduce health disparities in this population.

The effectiveness of a "restorative" model of care for home care patients.

1. Developed an operational definition of “maximizing functional independence” by developing a tool to identify and track patients’ functional assistance needs. 2. Identified structural, process, and attitudinal barriers to maximizing functional independence. 3. Identified strategies for overcoming barriers. 4. Tested these strategies, using small, local, shortcycle changes in clinical practice, making adjustments by using the build-up of experience and data as the process unfolded.

ReACH National Demonstration Collaborative: Early Results of Implementation

SUMMARY The Reducing Acute Care Hospitalization (ReACH) National Demonstration Collaborative is a two-year multi-wave initiative using a “virtual” Collaborative Learning Model to reduce acute care hospitalization rates among home care patients. ReACH aims to reduce hospitalization to 23%, as recommended by the Centers for Medicare and Medicaid Services in its 8th Scope of Work for Quality Improvement Organizations. This article reports on the early implementation experience of a sample of 17 of 65 home health agencies participating in Wave I of ReACH. It examines agency challenges in implementing a structured practice improvement initiative, improving hospital to home transitions and focusing appropriate resources on high risk patients. Lessons learned will inform future home health care quality improvement initiatives.

Exploring Diabetic Care Deficiencies and Adverse Events in Home Healthcare

&NA; Little information is available about the strength of the relationship between home healthcare practices and the potential adverse events the Centers for Medicare and Medicaid Services tracks through its uniform reporting system. We examined charts of patients who experienced a hyperglycemic or hypoglycemic emergent event to learn more about how home healthcare processes may contribute to an adverse event and to explore other factors that may contribute to a patients health outcome. Implicit peer review, informed by an explicit review process, determined that 10% of the emergent care events were probably avoidable if home care had been optimal, 56% were potentially avoidable, and 34% were unavoidable.

Can the Care Transitions Measure Predict Rehospitalization Risk or Home Health Nursing Use of Home Healthcare Patients

Abstract: The Care Transitions Measure (CTM) was designed to assess the quality of patient transitions from the hospital. Many hospitals are using the measure to inform their efforts to improve transitional care. We sought to determine if the measure would have utility for home healthcare providers by predicting newly admitted patients at heightened risk for emergency department use, rehospitalization, or increased home health nursing visits. The CTM was administered to 495 home healthcare patients shortly after hospital discharge and home healthcare admission. Follow‐up interviews were completed 30 and 60 days post hospital discharge. Interview data were supplemented with agency assessment and service use data. We did not find evidence that the CTM could predict home healthcare patients having an elevated risk for emergent care, rehospitalization, or higher home health nursing use. Because Medicare/Medicaid‐certified home healthcare providers already use a comprehensive, mandated start of care assessment, the CTM may not provide them additional crucial information. Process and outcome measurement is increasingly becoming part of usual care. Selection of measures appropriate for each service setting requires thorough site‐specific evaluation. In light of our findings, we cannot recommend the CTM as an additional measure in the home healthcare setting.

Improving the Transition to Home Healthcare by Rethinking the Purpose and Structure of the CMS 485: First Steps

ABSTRACT Transition points are the weak links in communication between providers. As an example, the discharge home often is a hurried “handoff” from inpatient physician to home care agency, whose visiting nurse admits the patient for a period of observation, medication management, rehabilitation, and teaching. The primary means of communication between physician and home health agency is the CMS 485, a form that contains the orders and that physicians frequently sign well after patients begin receiving services. This paper describes the first phase of a project that restructured and automated the CMS 485 using an existing electronic health record. The principles guiding the restructuring are described along with early reaction to and revision of the form to address operational issues. The paper also discusses evaluation plans and a web-based system of communication that will be developed in the second phase of the project.